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Springer Open Choice
PMC3429782
Journal of Hepato-Biliary-Pancreatic Sciences
J Hepatobiliary Pancreat Sci. 2012 Sep; 19(5): 548556.
Published online 2012 Jul 24. doi: 10.1007/s00534-012-0537-3
PMCID: PMC3429782
New diagnostic criteria and severity
assessment of acute cholangitis in revised
Tokyo guidelines
Seiki Kiriyama, 1 Tadahiro Takada,2 Steven M. Strasberg,3 Joseph S. Solomkin,4 Toshihiko
Mayumi,5 Henry A. Pitt,6 Dirk J. Gouma,7 O. James Garden,8 Markus W. Bchler,9
Masamichi Yokoe,10 Yasutoshi Kimura,11 Toshio Tsuyuguchi,12 Takao Itoi,13 Masahiro
Yoshida,14 Fumihiko Miura,2 Yuichi Yamashita,15 Kohji Okamoto,16 Toshifumi Gabata,17 Jiro
Hata,18 Ryota Higuchi,19 John A. Windsor,20 Philippus C. Bornman,21 Sheung-Tat Fan,22 Harijt
Singh,23 Eduardo de Santibanes,24 Harumi Gomi,25 Shinya Kusachi,26 Atsuhiko Murata,27
Xiao-Ping Chen,28 Palepu Jagannath,29 SungGyu Lee,30 Robert Padbury,31 and Miin-Fu Chen32
Author information Copyright and License information
This article has been cited by other articles in PMC.
Go to:
Abstract
Background
The Tokyo Guidelines for the management of acute cholangitis and cholecystitis were
published in 2007 (TG07) and have been widely cited in the world literature. Because of new
information that has been published since 2007, we organized the Tokyo Guidelines Revision
Committee to conduct a multicenter analysis to develop the updated Tokyo Guidelines
(TG13).
Methods/materials
We retrospectively analyzed 1,432 biliary disease cases where acute cholangitis was
suspected. The cases were collected from multiple tertiary care centers in Japan. The gold
standard for acute cholangitis in this study was that one of the three following conditions was
present: (1) purulent bile was observed; (2) clinical remission following bile duct drainage; or
(3) remission was achieved by antibacterial therapy alone, in patients in whom the only site
of infection was the biliary tree. Comparisons were made for the validity of each diagnostic
criterion among TG13, TG07 and Charcots triad.
Results
The major changes in diagnostic criteria of TG07 were re-arrangement of the diagnostic items
and exclusion of abdominal pain from the diagnostic list. The sensitivity improved from
82.8 % (TG07) to 91.8 % (TG13). While the specificity was similar to TG07, the false
positive rate in cases of acute cholecystitis was reduced from 15.5 to 5.9 %. The sensitivity of
Charcots triad was only 26.4 % but the specificity was 95.6 %. However, the false positive
rate in cases of acute cholecystitis was 11.9 % and not negligible. As for severity grading,
Grade II (moderate) acute cholangitis is defined as being associated with any two of the
significant prognostic factors which were derived from evidence presented recently in the
literature. The factors chosen allow severity assessment to be performed soon after diagnosis
of acute cholangitis.
Conclusion
TG13 present a new standard for the diagnosis, severity grading, and management of acute
cholangitis.
Keywords: Acute cholangitis, Biliary infection, Diagnostic criteria, Severity assessment,
Charcots triad
Go to:
Introduction
Patients with acute cholangitis are at risk for developing severe infection that can be fatal
unless appropriate medical care is provided at an early stage. Advances in antibiotic therapy
and acute care as well as a wide diffusion of expertise in biliary endoscopy have resulted in
reduction of morbidity and mortality from acute cholangitis. However, it remains a lifethreatening disease and early determination of disease severity is essential to select
appropriate therapy, particularly the timing of biliary decompression. In 2007, we conducted
a systematic review and sponsored an international consensus conference in Tokyo. This
meeting resulted in the introduction of the new Tokyo Guidelines (TG07) for diagnosis and
severity assessment of acute cholangitis [1].
Diagnostic and severity assessment criteria need to be updated periodically based on new
information, criticisms, and suggestions for improvement. For instance, ever since Charcot
reported a patient with severe acute cholangitis as a case of hepatic fever in 1877, Charcots
triad has been widely considered to be one of the most important diagnostic criteria [26].
However, Charcots triad has extremely low sensitivity despite its high specificity. In
addition, false positive cases of acute cholecystitis are not unusual with this classic diagnostic
triad.
With experience we and others found potential shortcomings in TG07 [7]. Consequently, the
Tokyo Guidelines Revision Committee was assembled and gathered a large number of cases
of acute cholangitis from tertiary care centers in Japan. These cases acted as a gold standard
to assess diagnostic and severity criteria such as TG07. The present study has confirmed
limitations of TG07 and presents updated TG13 criteria which have improved sensitivity and
specificity and which importantly, unlike the criteria in TG07, allow severity assessment at
the time of presentation so that biliary drainage or other procedures can be performed without
delay.
Go to:
Methods
In the present multicenter study, 1,432 patients were enrolled with biliary tract abnormalities
and suspected acute cholangitis between January 2007 and July 2011. Choledocholithisis or
biliary stricture was confirmed by direct cholangiography (i.e., endoscopic retrograde
cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography). Acute
cholecystitis was confirmed by pathologic examination of excised gallbladders.
The establishment of guidelines for diagnosis and severity assessment in a disease requires
that there is diagnostic certainty by which to assess criteria. For acute cholecystitis this may
be provided by pathologic examination of excised gallbladders; however, pathologic
specimens are not available in acute cholangitis. Our approach in this study was to gather
data from 794 patients who were considered to have had acute cholangitis based on one of the
following three criteria: (1) presence of purulent biliary leakage; (2) clinical remission due to
bile duct drainage; or (3) remission achieved by antimicrobial therapy alone in patients in
whom the only site of infection was the biliary tree. For comparison we also gathered data
from 638 patients who had other biliary tract abnormalities (Table 1).
Table 1
Clinical characteristics of patients
Using these patients, we adjusted diagnostic criteria to have the highest sensitivity and
specificity for acute cholangitis. For establishment of new severity assessment criteria, we
examined variables reported in the literature either as predictive of poor prognosis in acute
cholangitis or of need for urgent biliary drainage (Table 2). These variables were then used to
construct a grading system that would permit determination of the level of severity at the time
of diagnosis so that those patients who need urgent biliary decompression could receive
treatment without delay.
Table 2
Prognostic factors in acute cholangitis
For confirming the advantage of these revisions, updated diagnostic criteria and severity
assessment criteria also were retrospectively assessed by the present multicenter analysis.
Go to:
Results
Formulation of new diagnostic criteria for acute cholangitis
Assessment of Charcots triad and TG07 diagnostic criteria for acute cholangitis
Analysis of the 1,432 cases of biliary tract diseases showed that Charcots triad had low
sensitivity (26.4 %) but high specificity (95.9 %) for acute cholangitis, with 11.9 % of cases
of acute cholecystitis demonstrating Charcots triad. On the other hand, the sensitivity and
specificity of TG07 diagnostic criteria were 82.6 and 79.8 %, respectively, while 11.9 % of
cases acute cholecystitis would have fit the diagnostic criteria for acute cholangitis if TG07
criteria were applied (Table 3). Furthermore, TG07 diagnostic criteria for acute cholangitis
were found to have insufficient sensitivity for making an early diagnosis of life-threatening
acute cholangitis.
Table 3
Retrospective comparison of various diagnostic criteria of acute cholangitis in a multicenter
study in Japan
Revision of TG07 diagnostic criteria for acute cholangitis
It seemed that the shortcomings of TG07 might be related to inappropriate combination of
such items as clinical context and manifestations, laboratory data and imaging findings.
Therefore, for TG13, categories of diagnostic items were constructed based on the three main
clinical manifestations used in the diagnosis of acute cholangitis: (a) fever and/or evidence of
inflammatory response, (b) jaundice and abnormal liver function tests, and (c) abdominal
pain, a history of biliary diseases, biliary dilatation, or other biliary manifestations. The
presence of a finding in all three of these categories has been considered to be diagnostic of
acute cholangitis.
Abdominal pain and a history of biliary tract disease, however, are also common indicators of
other biliary problems such as acute cholecystitis and even acute hepatitis. Acute cholecystitis
application of the first draft criteria of TG13 (which included abdominal pain and a history of
biliary tract disease) to patients with acute cholecystitis resulted in 38.8 % of patients with
acute cholecystitis meeting the criteria for diagnosis of acute cholangitis. However, despite a
high sensitivity for acute cholangitis of 95.1 % for these diagnostic criteria the specificity of
(66.3 %) was disappointingly low (Table 3). In the next iteration of the diagnostic criteria,
abdominal pain and the history of biliary diseases were deleted from the diagnostic criteria.
This resulted in the best outcome in terms of high sensitivity and specificity for acute
cholangitis and low false positive rate for acute cholecystitis (Table 3) and these were the
diagnostic criteria which were adopted for TG13 (Table 3).
The final TG13 diagnostic criteria are shown in Table 4. To make a definitive diagnosis one
item from each of the three categories (AC) is required. Furthermore, a suspected
diagnosis can be made when there is one item present from the A list and one item from either
the B or C list. By establishing suspected diagnosis, early biliary drainage or source control
of infection among patients with acute cholangitis can be provided without waiting for a
definitive diagnosis.
Table 4
TG13 Diagnostic criteria for acute cholangitis
One of the items in category A involves determination of the presence of abnormal laboratory
tests. Thresholds for declaring positivity test might be set at the upper limit of normal for the
tests. The disadvantage of this approach is that minor abnormalities in the tests are not
uncommon in acute cholecystitis. Therefore, a somewhat higher threshold for acute
cholangitis is desirable. The normal upper limit range of the liver function tests differs from
facility to facility. Therefore, a fixed threshold is not practical. Instead, the threshold was set
at 1.5 times the upper limit of normal in a facility. We then conducted a multicenter analysis
to compare this threshold with two other types of threshold in terms of the diagnostic ability
for acute cholangitis. When the threshold was set at 1.5 times the upper limit, both sensitivity
and specificity were similar to those at which another two types of threshold were applied
(Table 5). From the above results, it was considered appropriate and practical that the
threshold was set at 1.5 times the normal upper limit for the liver function test in the
particular facility.
Table 5
Comparisons of various cut-offs for laboratory testing results for the diagnosis of acute
cholangitis in Japan
Formulation of new severity assessment criteria for acute cholangitis
Assessment of TG07 severity assessment criteria for acute cholangitis
The use of TG07 severity assessment criteria in actual clinical situations has shown that use
of these criteria was inefficient in separating moderate cases (Grade II) from mild cases
(Grade I) at the time of initial diagnosis. In TG07, Grades II and I were only assessed after
observation of the initial treatment courses. In this treatment strategy, urgent biliary drainage
can be indicated for cases assessed as severe, but provision of early biliary drainage is
impossible for cases as moderate. The present multicenter analysis showed that many cases
(46.8 %, 258 of 551 cases) of Grade II or I underwent urgent biliary drainage in the same
manner as Grade III. In these cases, differentiation between grade II and Grade I was
impossible, because the definition of Grade II in TG07 was ambiguous (Table 6).
Table 6
Timing of biliary drainage among patients with acute cholangitis diagnosed with TG07
multicenter analysis of acute cholangitis for revision of TG07 severity criteria of acute
cholangitis
Revision of TG07 severity assessment criteria for acute cholangitis
Given these insufficiencies of TG07 in clinical practice, a revision was sought which might
improve severity assessment strategies upon diagnosis in order to allow selection of those
patients who needed immediate source control of infection. Since there had been no
scientifically based definitions of moderate cases except for the consensus-based TG07 we
needed a new definition of what constituted moderate cases needing early source control in
TG13.
To improve TG07 we examined items reported as predictive factors of poor prognosis among
patients with acute cholangitis and factors associated with the need for urgent biliary drainage
(Table 2). Furthermore, factors that endoscopic gastroenterologists value in determining the
timing of biliary drainage were integrated except for the factors that define Grade III cases
(severe cases). Presence or absence of endotoxemia and/or bacteremia, and malignancy as
etiology cannot be assessed upon the diagnosis of acute cholangitis and were therefore not
included. Medical comorbidities such as diabetes mellitus and neurological diseases were
considered as severity factors; however, due to their wide disease spectrum, it was decided
that it was impractical to include co-morbidity in TG13. The criteria selected for moderate
severity were leukocytosis high fever, age >75 years, hyperbilirubinemia, and
hypoalbuminemia. The presence of any two of the five positive criteria will classify the
disease as Grade II (moderate).
The revised assessment criteria for acute cholangitis are shown in Table 7.
Table 7
TG13 Severity assessment criteria for acute cholangitis
Assessment of TG13 severity assessment criteria for acute cholangitis
We performed a multicenter analysis using the TG13 severity assessment criteria for acute
cholangitis in real clinical settings. Of the 623 cases of acute cholangitis where severity
grading was retrospectively made clear, there were 72 Grade III cases (11.6 %), 216 Grade II
cases (34.7 %) and 335 Grade I cases (53.8 %). Furthermore, the Grade II cases requiring
urgent or early biliary drainage accounted for 46 % of the acute cholangitis cases. An
examination of Grade I cases where biliary drainage had been carried out within 24 h and
within 48 h found 140 cases (41.8 %) and 181 cases (54.0 %), respectively. It was surprising
that so many patients with Grade I criteria had undergone biliary drainage. However, on
further analysis it was found that almost all Grade I cases that had undergone early biliary
drainage were due to biliary obstruction such as common duct stones. These types of
interventions accounted for 135 of 140 cases (94.8 %) within 24 h and 41 cases (100 %)
within 48 h, respectively. The number of Grade I cases that had undergone biliary drainage as
an urgent treatment to control infection were small (Table 8).
Table 8
Timing of biliary drainage among patients with acute cholangitis diagnosed with TG13
multicenter analysis of acute cholangitis for revision of TG07 Severity assessment criteria for
acute cholangitis
Of the 110 cases of acute cholangitis that met the Charcots triad, 13 cases (11.8 %) have
been classified as Grade III, and 52 as Grade II (47.3 %), respectively. Furthermore,
approximately 80 % (59 of 72 cases) of Grade III cases in TG13 failed to satisfy Charcots
triad (Table 9). Charcots triad was not found to be associated with disease severity.
Table 9
TG13 Severity assessment criteria and Charcots triad
Go to:
Discussion
The main goals of diagnostic and severity assessment criteria are to allow early establishment
of diagnosis and selection of the most appropriate management plan for the stage of the
disease. This was attempted for acute cholangitis in TG07 where the guidelines were based
on available literature and input of experts at a consensus conference held in Tokyo in 2006.
At that meeting, diagnostic criteria were presented combining blood tests and diagnostic
imaging together with Charcots triad [23]. However, there is a report showing that the
sensitivity was low (63.9 %) for making a definite diagnosis of acute cholangitis [7]. It is well
established that guidelines need periodic assessment and revision; however, in the case of
TG07 this was particularly so because of shortcomings that became evident through
application in clinical practice and as a result of new information in the literature. As in
TG07, initial iterations were produced in Japan with modifications incorporating the input of
experts from around the world.
A particularly vexing problem in studies of acute cholangitis is how to set a gold standard for
the disease against which to compare diagnostic and severity grading criteria. Unlike diseases
such as acute cholecystitis there is no organ or tissue with which absolute diagnosis of acute
cholangitis can be achieved pathologically. Therefore, a gold standard must be set by other
means. An important step in generation of TG13 was to adopt the three gold standard
diagnostic criteria suggested in the literature and by experience. This then permitted the
gathering of a large number of example cases by which to refine and judge the adequacy of
the new criteria. While this was an arduous task it seems that the results support this approach
in dealing with these issues. Another novelty in our approach is that the diagnostic criteria
were not judged simply against normal individuals but included patients with other biliary
tract diseases especially acute cholecystitis. This increases the robustness of the criteria as a
clinical tool.
The early iterations of the diagnostic criteria for TG13 included abdominal pain and a history
of biliary tract disease; however, it was found that inclusion of these criteria resulted in a
schema with low specificity and a high false positive rate in cases of acute cholecystitis.
When these variables were dropped the results improved dramatically. It may seem odd to
have diagnostic criteria which eliminate abdominal pain as a symptom of acute cholangitis
but the benefit of eliminating confusion with other biliary tract disease if pain is included
outweighs any advantage of including it.
The new TG13 diagnostic criteria have fewer variables and are arranged in more logical
categories. The thresholds for laboratory tests have been selected to permit worldwide use as
they do not depend on absolute values but on 1.5 times the upper limit of normal of any
laboratory. As such these criteria should be amenable to use on handheld devices further
improving the ability to rapidly diagnose the condition.
Ideally, a definitive diagnosis should be available at the time of presentation. If the
requirement for a definitive diagnosis results in delay of biliary drainage with progression to
more severe stages of the disease or death under observation the purpose of a definitive
diagnosis is subverted. At the present state of knowledge our data suggest that the decision to
proceed to early biliary drainage can and should be made on suspected diagnosis and severity
grading as outlined in the paper as both of these can be determined at presentation. The effect
of this strategy can be determined as the criteria for diagnosis are evaluated in the future.
The severity grading has also been revised based on new information available in the
literature. The criteria for severe cases have not been modified but those in the important
moderate group have been updated. As noted all five criteria in the moderate group are
determinable at presentation. This required the exclusion of a number of criteria as outlined in
the results.
In practice the diagnostic criteria and severity grading would be used in tandem at the time of
presentation. If a patient fit the suspected criteria, severity grading would be performed.
Those falling into the moderate and severe categories would be candidates for urgent biliary
decompression, while those in the mild category would be treated initially with antibiotics.
Many of the latter patients would still have biliary drainage within the first 48 h for control of
the cause of acute cholangitis such as extraction of common duct stones.
A diagnosis of acute cholangitis has traditionally been made by Charcots triad. According to
several reports, Charcots triad was observed for only 9 % except in cases of acute cholangitis
[8], but cases of acute cholangitis presenting all of Charcots triad accounted for only 50
70 % [3, 814, 2426]. We also continued to examine the utility of Charcots triad because of
the prominence of this diagnostic triad in this disease. We found that Charcots triad shows
very high specificitythe presence of the Charcots triad strongly suggested the presence of
acute cholangitis. However, due to the low sensitivity, it is not applicable in making a
diagnosis of acute cholangitis. Also as noted the triad was not associated with disease
severity.
In summary TG13 presents new diagnostic and severity grading systems based on a large
patients base and a reasonable gold standard. These criteria allow early diagnosis and severity
grading of the disease and should be clinically useful in the management of this severe
disease.
Go to:
Conclusion
TG13 introduces a new standard for the diagnosis, severity grading and management of acute
cholangitis. As compared with Charcots triad and TG07, validity of the diagnostic criteria
has been improved and severity assessment criteria have become more suitable for clinical
use.
Go to:
Open Access
This article is distributed under the terms of the Creative Commons Attribution License
which permits any use, distribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
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References
1. Wada K, Takada T, Kawarada Y, Nimura Y, Miura F, Yoshida M, et al. Diagnostic criteria
and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat
Surg. 2007;14:5258. doi: 10.1007/s00534-006-1156-7. [PMC free article] [PubMed] [Cross
Ref]
2. Dow R.W, Lindenauer SM. Acute obstructive suppurative cholangitis Ann Surg 1969;
169:2726 [PMC free article] [PubMed]
3. Welch JP, Donaldson GA. The urgency of diagnosis and surgical treatment of acute
suppurative cholangitis. Am J Surg. 1976;131:527532. doi: 10.1016/0002-9610(76)90003-9.
[PubMed] [Cross Ref]
4. BIet JH, Way LW. Acute cholangitis. Ann Surg 1980;191:26470. [PMC free article]
[PubMed]
5. Saharia PC, Cameron JL. Clinical management of acute cholangitis. Surg Gynec Obstet.
1976;142:369372. [PubMed]
6. Ostemiller W, Jr, Thompson RJ, Jr, Carter R, Hinshaw DB. Acute cholangitis. World J
Surg. 1984;8:963969. doi: 10.1007/BF01656040. [PubMed] [Cross Ref]
7. Yokoe M, Takada T, Mayumi T, Yoshida M, Hasegawa H, Norimizu S, et al. Accuracy of
the Tokyo Guidelines for the diagnosis of acute cholangitis and cholecystitis taking into
consideration the clinical practice pattern in Japan. J Hepatobiliary Pancreat Sci.
2011;18:250257. doi: 10.1007/s00534-010-0338-5. [PubMed] [Cross Ref]
8. Csendes A, Diaz JC, Burdiles P, Maluenda F, Morales E. Risk factors and classification of
acute suppurative cholangitis. Br J Surg. 1992;79:655658. doi: 10.1002/bjs.1800790720.
[PubMed] [Cross Ref]
9. Thompson J, Bennion RS, Pitt HA. An analysis of infectious failures in acute cholangitis.
HPB Surg. 1994;8:139144. doi: 10.1155/1994/73139. [PMC free article] [PubMed] [Cross
Ref]
10. Hui CK, Lai KC, Yuen MF, Ng M, Lai CL, Lam SK. Acute cholangitispredictive
factors for emergency ERCP. Aliment Pharmacol Ther. 2001;15:16331637. doi:
10.1046/j.1365-2036.2001.01071.x. [PubMed] [Cross Ref]
11. Gigot JF, Leese T, Dereme T, Coutinho J, Castaing D, Bismuth H. Acute cholangitis.
Multivariate analysis of risk factors. Ann Surg. 1989;209:435438. doi: 10.1097/00000658198904000-00008. [PMC free article] [PubMed] [Cross Ref]
12. Boey JH, Way LW. Acute cholangitis. Ann Surg. 1980;191:264270. doi:
10.1097/00000658-198003000-00002. [PMC free article] [PubMed] [Cross Ref]
13. Lai EC, Tam PC, Paterson IA, Ng MM, Fan ST, Choi TK, et al. Emergency surgery for
severe acute cholangitis. The high-risk patients. Ann Surg. 1990;211:5559. doi:
10.1097/00000658-199001000-00009. [PMC free article] [PubMed] [Cross Ref]
14. Lee CC, Chang IJ, Lai YC, Chen SY, Chen SC. Epidemiology and prognostic
determinants of patients with bacteremic cholecystitis or cholangitis. Am J Gastroenterol.
2007;102:563569. doi: 10.1111/j.1572-0241.2007.01095.x. [PubMed] [Cross Ref]
15. Tai DI, Shen FH, Liaw YF. Abnormal pre-drainage serum creatinine as a prognostic
indicator in acute cholangitis. Hepatogastroenterology. 1992;39:4750. [PubMed]
16. Andrew DJ, Johnson SE. Acute suppurative cholangitis, a medical and surgical
emergency. A review of ten years experience emphasizing early recognition. Am J
Gastroenterol. 1970;54:141154. [PubMed]
17. Rosing DK, De Virgilio C, Nguyen AT, El Masry M, Kaji AH, Stabile BE. Cholangitis:
analysis of admission prognostic indicators and outcomes. Am Surg 2007;73:94954
[PubMed]
18. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am.
2000;14:521546. doi: 10.1016/S0891-5520(05)70119-7. [PubMed] [Cross Ref]
19. Tsujino T, Sugita R, Yoshida H, Yagioka H, Kogure H, Sasaki T, et al. Risk factors for
acute suppurative cholangitis caused by bile duct stones. Eur J Gastroenterol Hepatol.
2007;19:585588. doi: 10.1097/MEG.0b013e3281532b78. [PubMed] [Cross Ref]
20. Shimada H, Nakagawara G, Kobayashi M, Tsuchiya S, Kudo T, Morita S. Pathogenesis
and clinical features of acute cholangitis accompanied by shock. Jpn J Surg. 1984;14:269
277. doi: 10.1007/BF02469641. [PubMed] [Cross Ref]
21. Yeom DH, Oh HJ, Son YW, Kim TH. What are the risk factors for acute suppurative
cholangitis caused by common bile duct stones? Gut Liver. 2010;4:3637. Epub 2010 Sep 24
[PMC free article] [PubMed]
22. Pang YY, Chun YA. Predictors for emergency biliary decompression in acute cholangitis.
Eur J Gastroenterol Hepatol. 2006;18:727731. doi: 10.1097/01.meg.0000219105.48058.df.
[PubMed] [Cross Ref]
23. Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T, Sekimoto M, et al.
Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J
Hepatobiliary Pancreatic Surg 2007; 14:110. [PMC free article] [PubMed]
24. Thompson JE, Jr, Tompkins RK, Longmire WP., Jr Factors in management of acute
cholangitis. Ann Surg. 1982;195:137145. doi: 10.1097/00000658-198202000-00003. [PMC
free article] [PubMed] [Cross Ref]
25. OConnor MJ, Schwartz ML, McQuarrie DG, Sumer HW. Acute bacterial cholangitis: an
analysis of clinical manifestation. Arch Surg. 1982;117:437441. doi:
10.1001/archsurg.1982.01380280031007. [PubMed] [Cross Ref]
26. Haupert AP, Carey LC, Evans WE, Ellison EH. Acute suppurative cholangitis. Experience
with 15 consecutive cases. Arch Surg. 1967;94:460468. doi:
10.1001/archsurg.1967.01330100024004. [PubMed] [Cross Ref]
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or cholangitis.[Am J Gastroenterol. 2007]
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